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What happened?
Workers reset the burner management control system on a heating, ventilation and air conditioning (HVAC) unit.
This started the automatic ignition sequence. It lit on the third cycle. The automated purge timer for each cycle was 7 seconds.
A worker opened the inspection and relief door to verify flame stability.
A flash fire occurred within 15 seconds and the worker received second degree burns to head, neck, and wrist.
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Why did it happen?
Another team had incorrectly installed a 7 second purge timer. The unit requires a 90 second purge.
After manual reset, the burner management system automatically steps through a purge, fan and logic permissive for pilot and main burner.
Burner inspection peep sight on the burner assembly was obstructed and lacked clear visibility.
Heating, ventilation and air conditioning’s inspection and relief door glass does not give clear visibility.
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What did they learn?
Use management of change to confirm that appropriate components are installed in equipment.
Personnel are at risk (e.g. line of fire) if components, such as view ports, are removed or obstructed.
Final/last minute risk assessment must be done before activities.
Only competent personnel should operate and maintain auxiliary utility equipment that poses risk to personnel.
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Ask yourself or your crew
How can something like this happen here?
What other actions could have been taken?
How do we verify management of change has been followed?
Are viewing ports obstructed? What can we do to solve this?
What risks have we not considered when working on heating, ventilation and air conditioning units?
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What happened?
Workers reset the burner management control system on a heating, ventilation and air conditioning (HVAC) unit.
This started the automatic ignition sequence. It lit on the third cycle. The automated purge timer for each cycle was 7 seconds.
A worker opened the inspection and relief door to verify flame stability.
A flash fire occurred within 15 seconds and the worker received second degree burns to head, neck, and wrist.
Why did it happen?
Another team had incorrectly installed a 7 second purge timer. The unit requires a 90 second purge.
After manual reset, the burner management system automatically steps through a purge, fan and logic permissive for pilot and main burner.
Burner inspection peep sight on the burner assembly was obstructed and lacked clear visibility.
Heating, ventilation and air conditioning’s inspection and relief door glass does not give clear visibility.
What did they learn?
Use management of change to confirm that appropriate components are installed in equipment.
Personnel are at risk (e.g. line of fire) if components, such as view ports, are removed or obstructed.
Final/last minute risk assessment must be done before activities.
Only competent personnel should operate and maintain auxiliary utility equipment that poses risk to personnel.
Ask yourself or your crew
How can something like this happen here?
What other actions could have been taken?
How do we verify management of change has been followed?
Are viewing ports obstructed? What can we do to solve this?
What risks have we not considered when working on heating, ventilation and air conditioning units?
A worker opened a heating, ventilation and air conditioning unit inspection and relief door to verify flame stability. A flash fire occurred within 15 seconds and the worker received second degree burns to head, neck, and wrist.
